Current Measures of Satisfaction Flawed, Could Cause Problems, Surgeons Say

Marcia Frellick

January 06, 2017

The current system of measuring patient satisfaction is flawed and incentivizes providers and healthcare administrators to make decisions that are not in the best interests of patients, and it also sometimes leads to poorer outcomes, a group of plastic surgeons argues.

At least one expert says the authors are only partially right.

Justin B. Cohen, MD, who worked in the Division of Plastic and Reconstructive Surgery at Washington University School of Medicine in St. Louis, Missouri, when the article was written, and colleagues, laid out their argument in an article published in the January issue of Plastic and Reconstructive Surgery.

Dr Cohen told Medscape Medical News that because patient satisfaction questionnaires are not tailored to specialties, the values of the answers are skewed.

For example, a patient with pancreatic cancer will have a much different perspective than someone being treated for depression or someone having a cardiology checkup, he noted.

"They will have very different expectations and very different happiness levels," said Dr Cohen, now a microsurgery fellow at Harvard School of Medicine in Boston, Massachusetts. "A lot of that isn't taken into account when we ask how happy they are that their pain was controlled."

The timing of the feedback is also an issue, he said. "You're asking people days, weeks, or months after their initial healthcare encounter about their impression of that experience. As we all know, there's a lot of recall bias, and bias in general."

Satisfaction Tied to Pay

One danger is that as the "pay for performance" aspect of the Affordable Care Act and Medicare makes patient satisfaction a factor in physician compensation, physicians are incentivized to placate patients by prescribing unnecessary antibiotics or narcotics or ordering laboratory tests not specified under current guidelines, Dr Cohen said. "I can tell you writing a narcotic prescription is a lot easier than having the discussion of why they don't need it or why you're concerned about them."

Also, penalizing physicians for things they cannot control, such as parking or food or nurse communication, is also unfair, Dr Cohen said.

In the article, the authors point to survey data published by the management consulting firm The Hay Group, which surveyed physicians in 167 healthcare groups and found that 66% said they had patient satisfaction as a primary factor in their incentive packages, but only 39% said outcomes were a performance metric.

"This patient-centered measure represented a 23 percent increase from the prior 2 years. Health care administrators appear to be sending a mixed message by saying that patient satisfaction outweighs outcomes," the authors write.

Hospital administrators may also make decisions to spend money on facilities and amenities that may increase satisfaction but not patient outcomes, Dr Cohen and colleagues point out.

"The truth is that there is little high-level evidence to support that patient satisfaction surveys will provide Americans with improved medical outcomes but there are plenty of contradictory data," they write.

The issue is highlighted in this article by plastic surgeons, a group greatly affected by patient feedback, especially in the cosmetic sector. As a specialty, plastic surgery also has little research available on how patient satisfaction relates to outcomes.

But the concerns apply to all of medicine, said coauthor Terence Myckatyn, MD, also from the Division of Plastic and Reconstructive Surgery at Washington University.

"Medical facilities in general are putting more resources in things like advertising or appearance, rather than outcomes," he told Medscape Medical News.

Keep the Surveys, but Change Them

The questionnaires are important, Dr Cohen and colleagues emphasize.

But as they stand now, factors such as whether patients liked the amenities are given weight similar to whether they were happy with their health outcome, Dr Myckatyn said.

Part of the challenge is public education, he said, and patients shopping for hospitals should consider what is most important in their decision.

There is wide agreement that patient feedback provides checks and balances.

"Many surgeons are more concerned about their technical acumen and their diagnostic abilities than their bedside manner," Dr Cohen said. "A lot of surgeons can get away with this...but that's probably going to have to change in the next generation."

However, the methods of gathering the information need to change, Dr Cohen said.

First, questionnaires should be specific to the area of care. Also, the list should also be short, "about 10 or 20 questions," with a comments section for people to elaborate, Dr Cohen added.

Expert: Better Patient Satisfaction, Better Outcomes

Thomas C. Tsai, MD, MPH, a surgeon and health policy researcher from the Department of Surgery at Brigham and Women's Hospital and the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health in Boston, disagrees with the authors regarding the possible link between patient surveys and better outcomes.

He said the body of evidence is overwhelming that there is a relationship between high patient satisfaction scores and better outcomes.

He led a study published in the Annals of Surgery that found that patient satisfaction was linked with quality and efficiency of surgical care and that hospitals with the highest satisfaction scores had the lowest mortality rates, shorter length of stay, and lowest readmission rates.

Dr Tsai said the questions asked in the surveys are reasonable, and as a surgeon, he wants to make sure patients get good outcomes, but also that they receive pain relief and get to go home and return to normal function in a reasonable amount of time.

"Patient satisfaction is fundamental to what we do. If we're not trying to serve our patients, then what are we doing?" he asked.

That said, he agreed with the authors that the questionnaires are not tailored to specialties, and said that is a fair criticism. However, he disagreed with them that the quest for higher scores will incentivize physicians to make poor care decisions.

"There's no data to suggest that in the literature," he said. He believes the anecdotal evidence is true, but large data sets do not bear that out.

The surveys are just one metric tied to quality of care, along with others including mortality, decreased wound infections, and better adherence to guidelines, Dr Tsai emphasized.

"If you can do all those and have high satisfaction of care, that means overall you are providing good, quality care, and I think everyone can agree on that," he said.

The authors and Dr Tsai have disclosed no relevant financial relationships.

Plast Reconstr Surg. 2017;139:257-261. Full text

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